CurrentBlue Cross Blue Shield - MichiganPolicy N/A

Blue Care Complete prescription drug coverage (Blue Care Complete Preferred Drug List)

Defines pharmacy coverage rules, exclusions, prior authorization and dispensing requirements for Blue Care Complete members in Michigan.

Policy Summary

PayerBlue Cross Blue Shield - Michigan

PolicyBlue Care Complete prescription drug coverage (Blue Care Complete Preferred Drug List)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization from BCN Clinical Pharmacy Help Desk for medications that require it and provide documentation of medical necessity or why formulary alternatives are inappropriate.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

34-daymaximum supply per prescription

0member copayment (Blue Care Complete)

14d / 72hPA decision timeframes

24/7PA phone availability

Coverage criteria

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Membership and network: Member is enrolled in Blue Care Complete and prescriptions are filled at a BCBSM/BCN network pharmacy (specialty medications may be filled through University of Michigan Health System pharmacies or other network retail pharmacies).

No mail-order benefit for nonspecialty drugs; specialty mail-order available via Walgreen's Specialty Pharmacy.

Formulary and generic dispensing: Drug is on the Blue Care Complete Preferred Drug List or has an authorized prior authorization; covered drugs available as generics will be dispensed as the generic version unless medical necessity for brand is approved.

Preferred Drug List is available online at MiBCN.com and is reviewed/updated monthly or as necessary.

Supply and cost-sharing: Prescriptions are limited to a 34-day supply and no copayment is required for covered drugs.34-day

Prescriptions filled after disenrollment or that provide more than a 34-day supply beyond termination are excluded.

The following categories of products are excluded from coverage for Blue Care Complete members unless specifically listed on the Michigan Pharmaceutical Product List (MPPL) or otherwise authorized: drugs to promote smoking cessation not on the MPPL; over-the-counter drugs not on the MPPL; most vitamins and mineral combinations (except when prescribed for end-stage renal disease, pediatric fluoride supplementation, or prenatal care); drugs for the symptomatic relief of cough and colds (note: codeine- and hydrocodone-containing products are covered); cosmetic drugs or drugs used for cosmetic purposes; drugs for infertility; drugs for sexual dysfunction; drugs used to treat gender identity conditions (such as hormone replacement); drugs to treat substance abuse; and drugs for anorexia or weight loss (except Xenical® for members meeting criteria, subject to quantity limits).

Additional exclusions include food supplements and standard infant formulas; drugs that are not FDA-approved; drugs used for experimental or investigational purposes or prescribed specifically for medical studies; and new drugs not yet added to the Blue Care Complete Preferred Drug List. Prescriptions filled after disenrollment or that provide more than a 34-day supply beyond a member's termination date are not covered.

Provider actions and prior authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for medications listed on the Blue Care Complete Preferred Drug List. Providers must request PA (or complete step therapy requirements) as indicated on the Preferred Drug List. To request prior authorization, contact the BCN Clinical Pharmacy Help Desk at 1-800-437-3803 (available 24/7). An interactive Blue Care Complete Medication Request Form is available at MiBCN.com and can be submitted directly to the BCN Clinical Pharmacy Help Desk. Blue Care Complete reviews PA requests based on medical necessity and will respond within 14 days; for urgent requests (where life, health, ability to regain maximum function, or severe uncontrolled pain is at risk), notify the Pharmacy Clinical Help Desk and a response will be provided within 72 hours.

PA and step therapy requirements are identified on the Blue Care Complete Preferred Drug List.
Contact BCN Clinical Pharmacy Help Desk: 1-800-437-3803 (24/7).
Interactive Medication Request Form: MiBCN.com.

Documentation Required

Documentation Required for Prior Authorization

Providers must supply documentation to support medical necessity for PA decisions. Documentation should include reasons why formulary alternatives are not appropriate for the member and, when requesting quantities above allowed limits, evidence that the allowed quantity is inadequate for the member's condition. For requests involving brand-name drugs available as generics, documentation of medical necessity is required; to substantiate a serious adverse event or quality issue with a covered generic, include a completed FDA MedWatch form with the Medication Request Form.

Provide clinical rationale why formulary alternatives are inappropriate.
If requesting higher than allowed quantity, include documentation showing allowed quantity is inadequate.
Include completed MedWatch form when claiming serious adverse events or quality issues with generics.

Denial Risk

Coverage Exclusions and PA Denials

Drugs that are excluded from Blue Care Complete coverage will be denied even if a PA is submitted. Common exclusions include, but are not limited to: non‑covered smoking cessation products not on the Michigan Pharmaceutical Product List; over‑the‑counter drugs not on the Michigan Pharmaceutical Product List; most vitamins/minerals (except specific indications); cosmetic drugs; infertility and sexual dysfunction drugs; many weight‑loss products (some exceptions may apply with criteria); food supplements and standard infant formulas; drugs not FDA‑approved; experimental or investigational drugs; prescriptions filled after member termination or beyond allowable supply limits; drugs covered by other plans (including Medicare Part D); new drugs not yet added to the Preferred Drug List; recalled or discontinued drugs; items provided at no cost to the provider; certain compounded products; and adulterated or fraudulent prescriptions. Additionally, some categories (e.g., HIV/AIDS, seizure disorders, sleep disorders, certain mental illness drugs) are covered by the state of Michigan rather than Blue Care Complete and will be denied here.

Excluded categories — examples: smoking cessation products not on Michigan list; OTC drugs not on Michigan list; vitamins/minerals except specified indications; cosmetic drugs; infertility and sexual dysfunction drugs; most weight‑loss drugs (exceptions may apply).
Other exclusions: food supplements, non‑FDA approved, experimental/investigational, prescriptions after enrollment termination or exceeding allowed supply, drugs covered by other plans (including Medicare Part D), new drugs not yet on the Preferred Drug List, recalled/discontinued drugs, items provided at no cost, certain compounded products, adulterated/fraudulent prescriptions.
Some drug categories (HIV/AIDS, seizure disorders, sleep disorders, certain mental illness drugs) are covered by the state of Michigan and not by Blue Care Complete.

Background

Blue Care Complete is a Medicaid-aligned prescription drug program for Michigan members. Coverage and dispensing are governed by the Blue Care Complete Preferred Drug List and medical necessity determinations; specialty medications may be dispensed through network specialty pharmacies (including University of Michigan Health System pharmacies and Walgreens Specialty Pharmacy for mail-order specialty). Prescriptions are limited to a 34-day supply, and covered drugs have no member copayment under the program.

Step therapy requirements

Step	Requirement	How to verify
1	Step therapy requirements are specified on the Blue Care Complete Preferred Drug List and must be followed before coverage of certain medications.	Confirm step therapy requirement on the Blue Care Complete Preferred Drug List; if required, verify member has attempted or failed formulary alternatives or submit documentation that alternatives are inappropriate.

Quantity limits and supply durations

All prescriptions — 34-day supply

Standard supply limit34-day supply per prescription

Network requirementPrescriptions must be filled at a BCBSM/BCN network pharmacy

Mail-order limitationNo mail-order benefit for nonspecialty drugs; specialty mail via Walgreens Specialty Pharmacy

Smoking cessation products on MPPL — 3 months

Covered smoking cessation productsProducts must be on the Michigan Pharmaceutical Product List (MPPL)

Enrollment requirementCoverage requires current enrollment in Quit the Nic (members call 1-800-811-1764 to enroll)

Quantity limitCoverage limited to three months every 12 months

Site of care and specialty distribution

Note

Specialty, mail-order and retail pharmacy sourcing

Specialty medications may be filled through University of Michigan Health System pharmacies or any other BCBSM/BCN network retail pharmacy; specialty drugs can be obtained by mail via Walgreen's Specialty Pharmacy (1-866-515-1355 or walgreenshealth.com). Nonspecialty drugs have no mail-order benefit. All prescriptions must be filled at a BCBSM/BCN network pharmacy.

Use University of Michigan Health System or other network retail pharmacies for specialty meds when not using specialty mail order.
To fill specialty drugs by mail, contact Walgreen's Specialty Pharmacy at 1-866-515-1355 or visit walgreenshealth.com.
No mail-order option for nonspecialty drugs — fill at network pharmacy.